By Tigistu A Ashengo
When I return home to Ethiopia, I look forward to visiting my grandparents’ house to reconnect with uncles, aunts and cousins with whom I share a closeness that belies my bi-continental life. Growing up in Addis Ababa, I spent my summers at my grandparents’ tukul, a cone-shaped mud hut nestled in the wide plain fields of the south that served as home, gathering place, familial retreat.
There were no secrets here—or so I thought.
The youngest of 6 children, my Uncle Mamo is a proud man who has spent most his life farming coffee, teff (Ethiopia’s super-grain) and sugar cane. Sitting around the fireplace drinking coffee, we talked about everything from health and the family crops to religion and the neighborhood schools where he once served as a security guard. I had forgotten how many children he had, so I asked.
At first, Mamo wasn’t certain himself. “I think 7, no 8. Oh wait, we lost one, so I think 7 now,” he said. The first 7 were all girls, and Mamo said, “We kept trying for a boy to help us with the farm when I get old.” But unfortunately, his wife developed a problem in her seventh pregnancy, and the baby girl died.
That problem was vesico-vaginal fistula, an abnormal opening between the vaginal canal and bladder that his wife Adanech developed after a prolonged and obstructed labor. It’s a problem that could have been prevented if Mamo and his wife had decided to go to the health facility earlier and had enough savings to jump on a bus to get them there. Instead, they waited for a miracle of birth. But the labor during Adanech’s seventh pregnancy was difficult. She pushed for 2 days with little result.
After making the highly controversial decision to sell 2 of their cattle—a milk cow and a farming oxen—they traveled the 18 kilometers so Adanech could deliver at Hosanna Hospital, a magnificent building that I recall admiring through a fence as a child.
Upon reaching the labor and delivery ward, they joined the misery of many women laboring— some on the floor, some sitting on a bench with their families. A nurse took Adanech with her relatives to a room where she examined her, naked and in front of both family and strangers.
Looking worried, the nurse set off to find the doctor on duty. As she did, she gave Mamo a prescription and told him to run to the pharmacy outside the hospital to buy IV fluids, and lots of medications. The nurse also asked for 2 units of blood to be donated, as the hospital’s blood bank was closed.
After another 24 hours of waiting for the doctor, medication and administrative processes, Adanech gave birth by cesarean section to a girl so distressed from the prolonged labor that she survived for little more than 10 minutes, despite efforts by the health care workers.
Adanech slowly recovered from the operation and the grief of losing her baby girl. But before long she developed a new but strange problem—she was leaking urine as a result of her long and difficult labor. But fearing that her in-laws saw her as a weak woman for losing the baby, Adanech put off seeking help. By the time she told her in-laws about the fistula, months later, her condition had worsened, with symptoms of infection such as fever and a bad smell.
Adanech lived through the shame and stigma of this condition, but went on to have yet another child, which was very risky. Luckily, that time she made it to the hospital in time for a C-section. When I asked Mamo why he decided to have another child after all that Adanech went through, he said he had no idea how to prevent a pregnancy—and once she was pregnant, “We thought it was going to be a boy this time…” and indeed it was a boy.
Such is a common story among many rural families in Ethiopia. Gaining access to health information, health facilities, emergency care, and family planning services is a very complicated endeavor. To have to pay for it out of pocket makes it only worse.
In March of this year, the Lancet Commission on Global Surgery published a compendium of articles on the many facets of improving access to surgical care for people like Adanech. The commission estimates that about 33 million individuals face catastrophic expenditure from accessing surgical and anesthesia care each year on the basis of out-of-pocket costs of surgery alone.
In rural parts of Ethiopia, this disparity is even worse. According to a cost-effectiveness analysis in the 3rd edition of the World Bank’s Disease Control Priorities (DCP-3), surgical access in Addis Ababa, the capital, approximates that of high-income countries. In contrast, rural areas face the dual challenge of poor access and catastrophic economic conditions like my uncle and his family faced.
Universal public financing of surgical care and use of non-specialist surgical care providers offer some hope for the poor, until highly skilled providers become available outside urban and peri-urban areas. As the DCP-3 states, “Impoverishment is not fully averted until patients no longer face non-medical costs of accessing care.” So providing essential and emergency services closer to the community shouldn’t wait until specialists are abundant.
Adanach would later have her fistula repaired at a hospital not far where I grew up, but Ethiopian families like my Uncle Mamo’s shouldn’t have to choose between basic health care and income-producing cattle. Accessing health services shouldn’t endanger a father’s already fragile ability to provide for his family and most importantly a mother’s life. The ability to have a C-section, repair a fistula or remove a cataract shouldn’t hinge on a fistful of dollars or a professional tradition, but a health system dedicated to serving people wherever they live.
Tigistu A Ashengo MD, MPH, is the Associate Medical Director of Jhpiego, a global health non-profit and affiliate of Johns Hopkins. He is co-editor of and contributor to “Operation Health: Surgical Care in the Developing World,” by Adam L. Kushner, Johns Hopkins University Press, 2015.
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Safe Surgery Panel
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September 25, 2015: Letter to the Editor re: “The Need for Essential Surgical Care in the Developing World.”
Thank you for posting Tigistu A. Ashengo's piece. I am the Operations Director at Global Emergency Care Collaborative and a JHSPH alumnus (MPH, MBA '08). Our organization has worked in Uganda since 2008 developing a training program for mid-level emergency care providers, called Emergency Care Practitioners (ECPs). We completely agree with Dr. Ashengo's assessment that providing essential and emergency services closer to the community shouldn’t wait until specialists are abundant.
Furthermore, we argue that coupling the development of emergency care with surgical care would help to address the large unmet burden of surgical disease in sub-Saharan Africa. By rapidly identifying and resuscitating patients requiring major operative care and providing non-operative management and definitive minor operative care, emergency care providers can help maximize the efficiency of surgeons and significantly improve their quality of life. Patients would benefit from more rapid diagnosis, early resuscitation, and increased access to operative care. While more research is required, integrating non-physicians into emergency care delivery models may allow these benefits to be realized by surgeons and patients in both urban and rural areas.
As an aside, I am a huge fan of your work at Global Health Now. I'm a daily consumer of your subscription emails and I'm continually impressed with the incredible range of topics and the quality of information you provide on a daily basis. I am very grateful for your efforts. Keep up the great work.—Tom Neill, MPH, MBA, Operations Director, Global Emergency Care Collaborative